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Food Benefit Filing Form
Aging and People with Disabilities
Agency use only
Date received:
Expedited services:
Client name:
Program:
Yes
No
Worker initials:
MA notice
Date sent:
Case number:
Branch code: Worker ID:
Worker phone:
Let us know if you need:
Language I speak:
An interpreter
A sign language interpreter
Written materials translated (what language):
Materials in:
Braille
Large print
Computer disk
Date of birth:
Audio tape
Oral presentation
If you are not registered to vote where you live now, would you like to apply to vote
today?
Yes
No
Applying to register to vote, or declining to register, will not affect the amount
of assistance you will be provided by this agency.
Important to file this form as soon as possible
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Complete this filing form first if you are applying for food benefits and return it
today. You may be eligible to receive benefits within seven days. Otherwise, fill
out the application form and turn it in at the time of your interview.
Client
Last name:
First name:
Address:
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MI:
SDS 0539F (10/13)
City:
Telephone:
Mailing address: (if different)
City:
I need a phone interview because I am:
other hardship:
State:
ZIP code:
State:
ZIP code:
Disabled
Elderly
Expedited food benefit information
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Does anyone have income of more than $150 a month?
Yes
No
Does anyone have more than $100 in cash or in their checking or savings
account?
Yes
No
Are your monthly rent and utility payments more than your monthly income, cash
and money in your bank accounts?
Yes
No
Is anyone a migrant or seasonal farm worker?
Yes
No
If “yes” answer the following questions:
Did you get paid before you applied for food benefits?
Yes
No
Will you get paid in the next 10 days?
Yes
No
Will your pay be more than $25?
Yes
No
All of the above information is true and correct to the best of my knowledge.
Client signature
Date:
Remarks/interview questions:
SDS 0539F (10/13)